Current through September 24, 2024
A. The Division
of Medicaid defines Diabetes Self-Management Training (DSMT) as an interactive
and collaborative process through which beneficiaries with diabetes gain the
knowledge and skills needed to modify their behavior and self-manage the
disease and its related conditions.
B. The Division of Medicaid does not enroll a
provider for the sole purpose of performing DSMT because DSMT is not a
separately recognized provider type. The provider seeking reimbursement for
DSMT must meet all of the required criteria set forth in Miss. Admin. Code Part
200, Rule 4.8 in addition to being:
1. A
current Mississippi Medicaid provider,
2. Located in the State of Mississippi, and
3. Accredited by the American
Diabetes Association (ADA) or the American Association of Diabetes Educators
(AADE).
C. The Division
of Medicaid covers DSMT when medically necessary, ordered by a physician,
physician assistant, or nurse practitioner who is actively managing the
beneficiary's diabetes, prior authorized by the Utilization Management/Quality
Improvement Organization (UM/QIO), the Division of Medicaid, or a designated
entity and when all the following criteria are met:
1. The beneficiary has been diagnosed with
diabetes by a physician,
2. The
services are provided under the direct supervision of a physician, physician
assistant, nurse practitioner, pharmacist or a registered nurse certified as a
diabetes educator, and
3. The
program meets the current ADA training standards.
D. The DSMT Plan of Care must include, but is
not limited to:
1. An assessment of the
beneficiary's specific needs for training,
2. Identification of the beneficiary's
specific diabetes self-management goals,
3. Behavioral interventions directed toward
helping the beneficiary achieve identified self-management goals, and
4. Evaluation of the beneficiary's
progress towards identified self-management goals.
E. DSMT includes:
1. One (1) initial training per lifetime
which:
a) Must be provided within a
continuous six (6) month period which begins with the initial individual
assessment visit.
b) Cannot exceed
a total of seven (7) hours, provided in increments no less than thirty (30)
minutes, which:
1) May include up to one (1)
hour of individual training for assessment of the beneficiary's training needs.
2) Includes up to six (6) hours of
training in a group setting consisting of two (2) or more individuals except
when the ordering physician determines:
(a) A
beneficiary would benefit from individual sessions instead of group sessions
which the physician's order must include a statement specifying DSMT training
in individual sessions along with an explanation, or
(b) A medical condition prevents the
beneficiary from completing the seven (7) hours of initial training within six
(6) months. Prior authorization for an extension to the six (6) month
time-frame must be obtained from the UM/QIO.
2. Follow-up training which:
a) Must be ordered by the physician actively
managing the beneficiary's diabetes, including documentation in the medical
record of the specific medical condition that the follow-up training must
address,
b) Is furnished any time
in a year following the year in which the beneficiary completes the initial
training,
c) Includes a maximum of
two (2) hours each year,
d) Is
furnished in increments of no less than thirty (30) minutes, and
e) Is provided in group sessions consisting
of two (2) or more individuals unless the ordering physician determines a
beneficiary would benefit from individual sessions instead of group sessions.
The physician's order must include a statement specifying DSMT training in
individual sessions along with an explanation.
F. Beneficiaries under the age of eighteen
(18) must be accompanied by a parent/guardian/legal representative.
G. The Division of Medicaid pays for all
medically necessary services for Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT)-eligible beneficiaries in accordance with Part 223 of Title
23, without regard to service limitations and with prior
authorization.
42 CFR §
410.141; Miss. Code Ann. §§
43-13-117,
43-13-121.
